Evaluation and Management (E/M) Services 1

The Seven Components of E/M Services

The descriptions for the levels of most E/M services recognize seven components, three of which are used
in defining the level of E/M services.

Key Components

 History
 Examination
 Medical Decision Making

Contributory Components

 Counseling
 Coordination of care
 Nature of presenting problem (illness)
 Time

Most often, the E/M codes are selected based on the documentation of the key components. Information
regarding at least two of the three key components (sometimes all three) must be documented in the
patient's medical record to substantiate certain levels of E/M codes. The key component requirements for
specific categories of E/M codes will be discussed later.

Time is the determining factor for certain E/M codes when counseling and/or coordination of care takes
up more than 50 percent of the total visit (face-to-face time in the office or other outpatient setting or
floor/unit time in the hospital or nursing facility). Time also is the controlling factor in certain E/M codes,
such as critical care and discharge day management.

A. Key Components

The Key components in selecting the level of E/M services are History, Examination, and Medical
Decision Making. These three key components appear in the descriptors for office or other outpatient
services, hospital observation services, hospital inpatient services, consultations, emergency department
services, nursing facility services, domiciliary care services, and home services.

1. History

The extent of history documented is dependent upon the physician's clinical judgment and the nature of
the presenting illness or problem. The types of history are defined BELOW:

Problem-Focused

 Chief Complaint;
 Brief History of Present Illness (HPI) or Problem

Expanded Problem-Focused

 Chief Complaint;

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Evaluation and Management (E/M) Services 2

 Brief History of Present Illness (HPI) or Problem,

 Problem-Pertinent System Review

Detailed

 Chief Complaint;
 Extended History of Present Illness (HPI) or Problem;
 Extended System Review;
 Pertinent Past, Family and/or Social History

Comprehensive

 Chief Complaint;
 Extended History of Present Illness (HPI) or Problem;
 Complete System Review;
 Complete Past, Family and Social History

Differences in 1995 vs. 1997 criteria:

The only difference is in the history of presenting illness criteria. The 1997 criteria allow inclusion of the
status of at least three chronic or inactive conditions or at least four current elements to establish an
extended history of presenting illness.

Each type of history includes some or all of the following elements:

a. Chief Complaint is a concise statement describing the symptom, problem, condition, diagnosis,
physician recommended return, or other factor that is the reason for the encounter. To qualify for a given
type of history, a chief complaint must be indicated at all levels.

b. History of Present Illness (HPI) is a chronological description of the development of the patient's
presenting illness or problem from the first sign and/or symptom, or from the previous encounter to the
present. There are two types of HPIs (brief and extended) which are distinguished by the amount of detail
included in the documentation for the following elements:

 Location - place, whereabouts, site, position. Where on the body is the patient experiencing signs
or symptoms? (e.g., pain in groin)
 Quality - A description, characteristics, or statement to identify the type of sign or symptom. (e.g.,
burning pain in groin).
 Severity - Degree, intensity, ability to endure. The patient may describe the severity of their signs
or symptoms by using a self-assessment scale to measure subjective levels. (e.g., History of mild
burning pain in groin that has become more intense)
 Duration - Length of time. How long has patient been experiencing the signs or symptoms? (e.g.,
History of intermittent mild burning pain in groin that has become more intense and frequent for
the last two weeks)
 Timing - Regulation of occurrence. A description of when the patient experiences signs or
symptoms (e.g., history of intermittent mild burning pain in groin that has become more intense
and frequent for the last two weeks).
 Context - Circumstances, cause, precursor, outside factors. A description of where the patient is
or what the patient does when the signs or symptoms are experienced (e.g., history of intermittent

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Evaluation and Management (E/M) Services 3

mild burning pain in groin that has become more intense and frequent for the last two weeks since
the patient bent down to pick up son and continues to feel intense pain when bending).
 Modifying Factors - Elements that change, alter or have some effect on the complaint or
symptoms (e.g., history of intermittent mild burning pain in groin that has become more intense
and frequent for last two weeks since the patient bent down to pick up son; continues to feel
intense pain when bending. (Patient currently on Motrin 800 mg BID for past 3 weeks without
relief)
 Associated Signs and Symptoms - Factors or symptoms that accompany the main symptoms.
What other factors does patient experience in addition to this discomfort/pain? (e.g., Shortness of
breath, lightheadedness, nausea/ vomiting)

A brief HPI consists of one to three (1 to 3) elements. An extended HPI consists of four or more (at least
four) elements, or the status of at least three chronic or inactive conditions (1997 criteria only).

c. Review of Systems (ROS) is an inventory of body systems obtained through a series of questions
seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. The
three types of ROS (problem pertinent, extended, and complete) are differentiated by the amount of
information included in the documentation for the following systems:

 constitutional symptoms (fever, weight loss, etc.)

 eyes
 ears, nose, mouth, throat
 cardiovascular
 respiratory
 gastrointestinal
 genitourinary
 musculoskeletal
 integumentary (skin and/or breast)
 neurological
 psychiatric
 endocrine
 hematologic/lymphatic
 allergic/immunologic

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the
HPI. The patient's positive responses and pertinent negatives for the system related to the problem should
be documented.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a
limited number of additional systems. The patient's positive and pertinent negative responses for two to
nine systems should be documented.

A complete ROS inquires about the system directly related to the problem(s) identified in the HPI plus all
additional body systems. At least ten organ systems must be reviewed. Those systems with positive or
pertinent negative responses must be individually documented. For the remaining systems, a notation
indicating all other systems are negative is permissible. In the absence of such a notation, at least ten
systems must be individually documented.

d. Past, Family and Social History (PFSH)

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Evaluation and Management (E/M) Services 4

The PFSH consists of a review of three history areas:

 past history includes recording of prior major illnesses and injuries; operations; hospitalizations;
current medications; allergies; age-appropriate immunization status; and/or age-appropriate
feeding/dietary status.
 family history involves the recording of the health status or cause of death of parents, siblings and
children; specific diseases related to problems identified in the chief complaint or history of
presenting illness and/or system review; and/or diseases of family members that may be
hereditary or place the patient at risk.
 social history contains marital status and/or living arrangements; current employment;
occupational history; use of drugs, alcohol and tobacco; level of education; sexual history; or
other relevant social factors.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the
HPI. At least one specific item for any of the three history areas must be documented.

A complete PFSH is a review of two or all three of the history area(s), depending on the category of the
E/M service.

 At least one specific item from two of the three history areas must be documented for the
following categories of E/M services: office or other outpatient services (established patient);
emergency department; subsequent nursing facility care; domiciliary care (established patient);
and home care (established patient).
 at least one specific item from each of the three history areas must be documented for the
following categories of E/M services: office or other outpatient services (new patient); hospital
observation services; hospital inpatient services (initial care); consultations; comprehensive
nursing facility assessments; domiciliary care (new patient); and home care (new patient).
 Categories of subsequent hospital care, follow-up inpatient consultations and subsequent
nursing facility care, domiciliary care (established patient); and home care (established patient)
require only an "interval" history. It is necessary to record only the changes in the PFSH that
have occurred since the previous documentation of the history areas.

Note: All three elements (HPI, ROS and PFSH) must be

documented to qualify for a detailed or comprehensive history.

e. Additional Guidelines for Documenting History Component

o The chief complaint, ROS and PFSH may be listed as separate elements of history, or they
may be included in the description of the HPI.
o A ROS and/or PFSH obtained during an earlier encounter does not need to be recorded
again if there is evidence that the physician reviewed and updated the previous
information. This update may be documented by: describing any new ROS and/or PFSH
information or noting any changes in the information; and noting the date and location of
the earlier ROS and/or PFSH either on the list form or in the documentation itself. This
form must be signed by the physician.

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Evaluation and Management (E/M) Services 5

o The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the
patient. To document that the physician reviewed the information, there must be a
notation supplementing or confirming the information recorded by others. For example,
using a checklist as an alternative method of documentation is acceptable when the
physician: indicates his/her review of the information; details all abnormal (or positive)
findings; and references the checklist in the progress note.
o If the physician is unable to obtain a history from the patient or other source, the record
should describe the patient's condition or other circumstance that precludes obtaining a
history and should note the inability to obtain the history from the patient.
o If ROS/PFSH are non-contributory or negative after assessment, the physician should
document these areas accordingly.

 SUMMARY OF HISTORY COMPONENTS AND

DOCUMENTATION REQUIREMENTS

EXPANDED
LEVEL OF PROBLEM
PROBLEM  DETAILED  COMPREHENSIVE
HISTORY FOCUSED
FOCUSED
 4 or more
 HPI  1-3 elements  1-3 elements  4 or more elements
elements
 ROS  0  1 element  2-9 elements  10 or more elements
 PFSH  0  0  1 element  2 or 3 elements

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Evaluation and Management (E/M) Services 6

A. Comparison of 1995 E/M Documentation Requirements to 1997 E/M Documentation Requirements

History Examination
(3 out of 3 components must be met or exceeded)
    1995 Requirements
   1997 Requirements

 
Chief Complaint: (required) Chief Complaint: (required)

 Concise statement of reason for  Concise statement of reason for treatment

treatment must be documented for all must be documented for all levels of service
levels of service

 
(1) History of Presenting Illness: (1) History of Presenting Illness:

 Chronological description of patient's  Chronological description of patient's

present illness from first sign/symptom present illness from first sign/symptom or
or from previous encounter to present. from previous encounter to present.

Brief: 1-3 elements Brief: 1-3 elements

Extended: 4 or more elements Extended: 4 or more elements or the status of at least
three chronic or inactive conditions

 (2) Review of Systems: (2) Review of Systems:

 Inventory of body systems by questioner to
 Inventory of body systems by identify signs/symptoms patient is
questioner to identify signs/symptoms experiencing or may have experienced.
patient is experiencing or may have
experienced. Problem pertinent: 1 element
Extended: 2-9 elements
Problem pertinent: 1 element Complete: 10 or more elements or documentation of
Extended: 2-9 elements positive or pertinent negative responses with
Complete: 10 or more elements or additional documentation of "all other systems are
documentation of  positive or pertinent negative negative"
responses with additional documentation of "all
other systems are negative"

  (3) Past, Family & Social History: (3) Past, Family & Social History:
 Review of three areas: past medical  Review of three areas: past medical history,
history, family history including family history including hereditary diseases
hereditary diseases or place the patient or place the patient at risk and age
at risk and age appropriate social appropriate social history.
history
Pertinent: 1 element
Pertinent: 1 element Complete: 3 elements must be documented for new
Complete: 3 elements must be documented for patients; 2/3 elements must be documented for

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Evaluation and Management (E/M) Services 7

new patients; 2/3 elements must be documented established or ER patients

for established or ER patients

 * The only difference between the 1995 vs. 1997 history criteria is in the history of presenting illness. The
1997 criteria allows inclusion of the status of at least three chronic or inactive conditions or at least four
current elements to establish an extended history of presenting illness.

 2. Physical Examination

The extent of examination performed and documented is dependent upon clinical judgment, the patient's
history, and the nature of the presenting problem(s). They range from limited examination of single body
areas to general multi-system or complete single organ system examinations.

Differences in 1995 vs. 1997 criteria:

The 1995 criteria allows use of both a general multi-system exam or single specialty exam criteria but
does not define documentation elements for the single specialty exam. General multi-system exam criteria
defines the number of elements which must be documented in each type of examination but the content
and performance elements are left to the clinical judgement of the physician.

Using the 1997 criteria, documentation elements for a general multi-system examination or a single organ
system examination are clearly defined by "bullets." Any physician regardless of specialty may use the
general multi-system criteria or a single organ system examination. The 1997 criteria requires
performance of all elements in a body area/organ system but documentation of only 2 bullets to "count"
in level of service determination.

a. Types of Examinations

The levels of E/M services are based on four types of examination:

Problem Focused -- a limited examination of the affected body area or organ system.

Expanded Problem Focused -- a limited examination of the affected body area or organ system and
any other symptomatic or related body area(s) or organ system(s).

Detailed -- an extended examination of the affected body area(s) or organ system(s) and any other
symptomatic or related body area(s) or organ system(s).

Comprehensive -- a general multi-system examination, or complete examination of a single organ

system and other symptomatic or related body area(s) or organ system(s).

b. The Body Areas and Organ Systems

The AMA and HCFA define body areas as:

head, including the face;

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Evaluation and Management (E/M) Services 8

neck;

chest, including breasts and axilla;

abdomen;

genitalia, groin and buttocks;

back; and

each extremity.

The AMA and HCFA define organ systems as:

eyes;

ears, nose, mouth, throat;

cardiovascular;

respiratory;

gastrointestinal;

genitourinary;

musculoskeletal;

skin;

Neurologic;

psychiatric;

hematologic/lymphatic/immunologic.

Note: Medicare recognizes "constitutional (e.g., vital signs, general appearance)" as an organ system for the
physical examination.

c. GENERAL MULTI-SYSTEM EXAMINATIONS (1997 criteria)

General multi-system examinations are described in detail below. To qualify for a given level of multi-
system examination, the following content and documentation requirements should be met:

Problem Focused Examination--should include performance and documentation of one to five

elements identified by a bullet (·) in one or more organ system(s) or body area(s).

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 Evaluation and Management (E/M) Services 9

Expanded Problem Focused Examination--should include performance and documentation of at least

six elements identified by a bullet (·) in one or more organ system(s) or body area(s).

Detailed Examination--should include at least six organ systems or body areas. For each system/area
selected, performance and documentation of at least two elements identified by a bullet (·) is
expected. Alternatively, a detailed examination may include performance and documentation of at
least twelve elements identified by a bullet (·) in two or more organ systems or body areas.

Comprehensive Examination--should include at least nine organ systems or body areas. For each
system/area selected, all elements of the examination identified by a bullet (·) should be
performed, unless specific directions limit the content of the examination. For each area/system,
documentation of at least two elements identified by a bullet is expected.

CONTENT AND DOCUMENTATION REQUIREMENTS General

Multi-System Examination (1997 criteria)

Organ System/Body Area Elements of Examination

 Measurement of any three of the following seven vital signs:

1) sitting or standing blood pressure

2) supine blood pressure
3) pulse rate and regularity
  4) respiration
Constitutional  5) temperature
6) height
7) weight (May be measured and recorded by ancillary staff)

 General appearance of patient (e.g., development, nutrition,

body habitus, deformities, attention to grooming)
 Eyes Inspection of conjunctivae and lids
 Examination of pupils and irises (e.g., reaction to light and
accommodation, size and symmetry)
 
Eyes  Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio,
appearance) and posterior segments (e.g., vessel changes,
exudates, hemorrhages)

   Ears, Nose, Mouth and Throat External inspection of ears and

Ears, Nose, Mouth nose (e.g., overall appearance, scars, lesions, masses)
and Throat  Otoscopic examination of external auditory canals and tympanic
membranes
 Assessment of hearing (e.g., whispered voice, finger rub, tuning
fork)
 Inspection of nasal mucosa, septum and turbinates
 Inspection of lips, teeth and gums
 Examination of oropharynx: oral mucosa, salivary glands, hard
and soft palates, tongue, tonsils and posterior pharynx

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 Evaluation and Management (E/M) Services 10

 Examination of neck (e.g., masses, overall appearance, symmetry,

  tracheal position, crepitus)
Neck  Examination of thyroid (e.g., enlargement, tenderness, mass)

 Assessment of respiratory effort (e.g., intercostal retractions, use

of accessory muscles, diaphragmatic movement)
 Percussion of chest (e.g., dullness; flatness, hyperresonance)
  Respiratory  Palpation of chest (e.g., tactile fremitus)
 Ausculation of lungs (e.g., breath sounds, adventitious sounds,
rubs)

Organ System/Body Area Elements of Examination

   Palpation of heart (e.g., location, size, thrills)
 Auscultation of heart with notation of abnormal sounds and
murmurs

 Examination of:
Cardiovascular o carotid arteries (e.g., pulse amplitude, bruits)
o abdominal aorta (e.g., size bruits)
o femoral arteries (e.g., pulse amplitude, bruits)

 pedal pulses (e.g., pulse amplitude)

 extremities for edema and/or varicosities

 Inspection of breasts (e.g., symmetry, nipple discharge)

 
 Palpation of breasts and axillae (e.g., masses or lumps,
Chest
(Breasts) tenderness)

 Examination of abdomen with notation of presence of masses or

tenderness
   Examination of liver and spleen
Gastrointestinal  Examination for presence or absence of hernia
(Abdomen)  Examination (when indicated ) of anus, perineum and rectum,
including sphincter tone, presence of hemorrhoids, rectal masses
 Obtain stool sample for occult blood test when indicated

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 Evaluation and Management (E/M) Services 11

 Palpation of lymph nodes in two or more areas:

   Neck
Lymphatic  Axillae
 Groin
 Other

Organ System/Body Area Elements of Examination

 Examination of gait and station
 Inspection and/or palpation of digits and nails (e.g., clubbing,
cyanosis, inflammatory conditions, petechiae, ischemia, infections,
nodes)

 Examination of joints, bones and muscles of one or more of the

following six areas:
1) head and neck;
2) spine, ribs and pelvis;
3) right upper extremity;
4) left upper extremity;
5) right lower extremity; and
6) left lower extremity.
 
Musculoskeletal
 The examination of a given area includes:
o Inspection and/or palpation with notation of presence of
any misalignment, asymmetry, crepitation, defects,
tenderness, masses, effusions
o Assessment of range of motion with notation of any pain,
crepitation or
o Contracture
o Assessment of stability with notation of any dislocation
(luxation), subluxation or  laxity
o Assessment of muscle strength and tone (e.g., flaccid, cog
wheel, spastic) with notation of any atrophy or abnormal
movements

 Inspection of skin and subcutaneous tissue (e.g., rashes, lesions,

ulcers)
 
 Palpation of skin and subcutaneous tissue (e.g., induration,
Skin
subcutaneous nodules, tightening

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 Evaluation and Management (E/M) Services 12

 Test cranial nerves with notation of any deficits

 Examination of deep tendon reflexes with notation of pathological
 
reflexes (e.g., Babinski)
Neurologic
 Examination of sensation (e.g., by touch, pin, vibration,
proprioception)

 Description of patient's judgment and insight

 Brief assessment of mental status including:
 
o Orientation to time, place and person
Psychiatric
o Recent and remote memory
o Mood and affect (e.g., depression, anxiety, agitation)

 Content and Documentation Requirements

   
Level of Exam Perform and Document:
 
Problem Focused  One to five elements identified by a bullet.
 
Expanded Problem  At least six elements identified by a bullet.
 Focused
 At least two elements identified by a bullet from each of six areas/
 
systems OR at least twelve elements identified by a bullet in two or more
Detailed
areas/systems.
 Perform all elements identified by a bullet in at least nine organ systems
or body areas.
 
Comprehensive
Document at least two elements identified by a bullet from each of nine
areas/systems.

d. SINGLE-ORGAN SYSTEM EXAMINATIONS (See Appendix B)

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Evaluation and Management (E/M) Services 13

The AMA and HCFA have identified the following single organ systems:

 Cardiovascular
 Ears, Nose, Mouth and Throat
 Eyes
 Genitourinary (Female)
 Genitourinary (Male)
 Hematologic/Lymphatic/Immunologic
 Musculoskeletal
 Neurological
 Psychiatric
 Respiratory
 Skin

The single organ system examinations recognized by CPT are described in detail below. Variations
among these examinations in the organ systems and body areas identified in the left columns and in the
elements of the examinations described in the right columns reflect differing emphases among specialties.
To qualify for a given level of single organ system examination, the following content and documentation
requirements should be met:

 Problem Focused Examination--should include performance and documentation of one to five

elements identified by a bullet (·), whether in a shaded or unshaded box.
 Expanded Problem Focused Examination--should include performance and documentation of at
least six elements identified by a bullet (·), whether in a shaded or unshaded box.
 Detailed Examination--examinations other than the eye and psychiatric examinations should
include performance and documentation of at least twelve elements identified by a bullet (·),
whether in a shaded or unshaded box.
 Eye and Psychiatric examinations should include the performance and documentation of at least
nine elements identified by a bullet (·), whether in a shaded or unshaded box.
 Comprehensive Examination--should include performance of all elements identified by a bullet
(·), whether in a shaded or unshaded box. Documentation of every element in a shaded box and at
least one element in each unshaded box is expected.

 e. Additional Documentation Guidelines

 Specific abnormal and relevant findings of the examination of the affected or symptomatic body
area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration
is insufficient documentation.
 Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ
system(s) should be described.
 A brief statement or notation indicating "negative" or "normal" is sufficient to document
findings that have been determined as being within normal limits. However, "exam normal" or
"exam negative" is unacceptable documentation. The normal or negative findings must be listed
by body area or organ system.*
 Recent clarification from HCFA indicates that stating "Cardiovascular, negative" is not
considered sufficient documentation to meet the criteria for the higher level examinations. The
physician needs to be more specific by indicating the elements which are negative.

 Physical Examination

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Evaluation and Management (E/M) Services 14

   
 1995 Requirements*  1997 Requirements
 Problem Focused Examination:
  Problem Focused Examination:
 Limited to affected body area or organ
 One to five element(s) in one or more
system
organ system(s) or body area(s).

 Expanded Problem Focused Examination:  Expanded Problem Focused Examination:

 A limited examination of the affected  Six elements in one or more organ
body area or organ system and other system(s) or body area(s).
symptomatic or related organ system(s).

 Two to seven body areas or organ

systems

 Detailed Examination:  Detailed Examination:

 An extended examination of the affected  At least six organ systems or body
body area(s) and other symptomatic or area(s). For each of the six organ
related organ system(s). systems or body areas, at least two
elements identified by a bullet is
 Two to seven body areas or organ expected; OR
systems.
At least twelve elements identified by a bullet in
two or more organ systems or body areas.
   
Comprehensive Examination : Comprehensive Examination:

 A general multi-system examination or  At least nine organ systems or body

a complete examination of a single areas.
organ system *.  For each organ system/body area, ALL
elements identified by a bullet should be
 Eight or more organ systems. performed.
 For each organ system/body area,
documentation of at least two elements
identified by a bullet is expected.

* 1995 criteria do not define documentation elements for a single organ system exam.

 3. Medical Decision Making

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a
management option. No differences in documentation requirements are noted between 1995 and 1997
criteria. The levels of E/M services recognize four types of medical decision making:

 Straightforward

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Evaluation and Management (E/M) Services 15

o minimal number of diagnoses or management options considered

o little, if any, amount or complexity of data reviewed
o minimal risk of complications or morbidity or mortality (expectation of full recovery
without functional impairment)

Low Complexity

 limited number of diagnoses or management options considered

 limited amount and complexity of data reviewed
 low risk of complications or morbidity or mortality (uncertain outcome or increased probability
of prolonged functional impairment

 Moderate Complexity

 multiple number of diagnoses or management options considered

 moderate amount and complexity of data reviewed
 moderate risk of complications or morbidity or mortality (uncertain outcome or increased
probability of prolonged functional impairment or high probability of severe prolonged functional
impairment)

High Complexity

 extensive number of diagnoses or management options considered

 extensive amount and complexity of data reviewed
 high risk of complications or morbidity or mortality (uncertain outcome or increased probability
of prolonged functional impairment or high probability of severe prolonged functional
impairment)

a. Number of Diagnoses or Management Options

The number of possible diagnoses and/or the number of management options that must be considered is
based on the number and types of problems addressed during the encounter, the complexity of
establishing a diagnosis, and the management decisions that are made by the physician.

The types of presenting problems (the fourth component) are:

1. minimal: problem not requiring presence of physician but service is provided under the physician's
supervision.

2. self-limited or minor: problem that runs a definite and prescribed course, is transient in nature, not
likely to permanently alter patient's health status, has good prognosis with management and compliance.

3. low severity: problem where risk of morbidity without treatment is low; little or no risk of mortality
without treatment, full recovery without functional impairment.

4. moderate severity: problem where risk of morbidity without treatment is moderate; moderate risk of
mortality without treatment; uncertain prognosis or increased probability of functional impairment.

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Evaluation and Management (E/M) Services 16

5. high severity: problem where risk of morbidity without treatment is high to extreme; there is a
moderate risk of mortality without treatment or high probability of severe, prolonged functional
impairment.

 For each encounter, an assessment, clinical impression or diagnosis should be documented. It may be
explicitly stated or implied in documented decisions regarding management plans and/or further
evaluations.

 For a presenting problem with an established diagnosis the record should reflect whether the
problem is:
a) improved, well controlled, resolving or resolved; or
b) inadequately controlled, worsening or failing to change as expected.
 For a presenting problem without an established diagnosis, the assessment or clinical impression
may be stated in the form of a differential diagnosis or as "possible," "probable" or "rule out"
(R/O) diagnoses.
 The initiation of changes in treatment should be documented. Treatment includes a wide range of
management options, including patient instructions, nursing instructions, therapies and
medications.
 If referrals are made, consultations requested or advice sought, the record should indicate to
whom or where the referral or consultation is made or from whom the advice is requested.

 b. Amount and/or Complexity of Data to be Reviewed

The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or
reviewed. A decision to obtain and review old medical records and/or obtain history from sources other
than the patient increases the amount of complexity of data to be reviewed.

 Data should be documented as follows:

 If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time
of the E/M encounter, the type of service (e.g., lab or x-ray), should be documented.
 The review of lab, radiology and/or other diagnostic tests should be documented. An entry in the
progress note, such as "WBC elevated" or "chest x-ray unremarkable" is acceptable.
Alternatively, the review may be documented by initialing and dating the report that contains the
test results.
 A decision to obtain old records or decision to obtain additional history from the family,
caregiver, or other source to supplement information obtained from the patient should be
documented.
 Relevant findings from the review of old records, and/or the receipt of additional history from the
family, caretaker or other source should be documented. If there is no relevant information
beyond that already obtained, that fact should be documented. A notation of "old records
reviewed" or "additional history obtained from family" without elaboration is insufficient.
 The results of discussion of laboratory, radiology or other diagnostic tests with the physician who
performed or interpreted the study should be documented.
 The direct visualization and independent interpretation of an image, tracing or specimen
previously or subsequently interpreted by another physician, should be documented.

c. Risk of Significant Complications, Morbidity and/or Mortality

The risk of significant complications, morbidity and/or mortality is based on the risks associated with the

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Evaluation and Management (E/M) Services 17

presenting problem(s), the diagnostic procedure(s) and the possible management options. Information to
include:

 Comorbidities/underlying diseases or other factors that increase the complexity of medical

decision making by increasing the risk of complications, morbidity, and/or mortality should be
documented.
 If a surgical or invasive diagnostic procedure is ordered, planned or scheduled at the time of the
E/M encounter, the type of procedure (e.g., laparoscopy), should be documented.
 If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the
specific procedure should be documented.
 The referral for, or decision to perform, a surgical or invasive diagnostic procedure on an urgent
basis should be documented or implied.

The following table may be used to help determine whether the risk of significant complications,
morbidity, and/or mortality is minimal, low, moderate or high. Because the determination of risk is
complex and not readily quantifiable, the table includes some common clinical examples rather than
absolute measures of risk.

The assessment of risk of the presenting problem(s) is based on the risk related to the disease process
anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic
procedures and management options is based on the risk during, and immediately following, any
procedures or treatment. The highest level of risk in any one category [presenting problem(s), diagnostic
procedure(s), or management option(s)] determines the overall risk.

E/M TABLE OF RISK

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Evaluation and Management (E/M) Services 18

 Level of  Diagnostic Procedure(s)  Management Options

 Presenting Problem(s)
Risk Ordered Selected

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Evaluation and Management (E/M) Services 19

  one self-limited or minor laboratory tests requiring:   rest

problem, e.g., cold, insect  venipuncture  gargles
bite, tinea corporis  chest x-rays  elastic bandages
 EKG/EEG  superficial dressings
 Minimal  urinalysis
 ultrasound  
 echocardiography

 KOH prep
  two or more self-limited   physiologic tests not   over-the-counter
or minor problems under stress, e.g., drugs
 one stable chronic illness, pulmonary function tests  minor surgery with no
e.g., well controlled  non-cardiovascular identified risk factors
hypertension, non-insulin- imaging studies with  physical therapy
dependent diabetes, contrast, e.g., barium  occupational therapy
 Low cataract, BPH enema
 superficial needle biopsies  IV fluids without
 acute uncomplicated  clinical laboratory tests additives
illness or injury, e.g., requiring arterial
cystitis, allergic rhinitis, puncture
simple sprain
 skin biopsies
  one or more chronic   physiologic test under   minor surgery with
illnesses with mild stress, e.g., cardiac stress identified risk factors
exacerbation, progression, test, fetal contraction  elective major surgery
or side effects of treatment stress test (open, percutaneous,
 two or more stable chronic  diagnostic endoscopies endoscopic) with no
illnesses with no identified risk identified risk factors
 undiagnosed new problem factors  prescription drug
with uncertain prognosis,  deep needle or incisional management
e.g., lump in breast biopsy  therapeutic nuclear
 Moderate  acute illness with  cardiovascular imaging medicine
systematic symptoms, e.g., studies with contrast and  IV fluids with
pyelonephritis, no identified risk factors additives
pneumonitis, colitis e.g., arteriogram, cardiac
 acute complicated injury, catheterization  closed treatment of
e.g., head injury with brief fracture or dislocation
loss of consciousness  obtain fluid from body without manipulation
cavity, e.g., lumbar
  puncture, thoracentesis,
culdocentesis
 High   one or more chronic   cardiovascular imaging  elective major surgery
illnesses with severe studies with contrast with (open, percutaneous,
  exacerbation, progression, identified risk factors or endoscopic) with
or side effects of treatment  cardio electrophysiological identified risk factors
   acute or chronic illnesses tests  emergency major
or injuries that may pose a  diagnostic endoscopies surgery (open,
  threat to life or bodily with identified risk factors percutaneous, or

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 Evaluation and Management (E/M) Services 20

function, e.g., multiple  discography endoscopic)

trauma, acute MI,  parenteral controlled
  pulmonary embolus,   substances
severe respiratory  drug therapy
  distress, progressive   requiring intensive
severe rheumatoid monitoring for toxicity
arthritis, psychiatric  
 
illness with potential  decision not to
threat to self or others,   resuscitate or to de-
  peritonitis, acute renal escalate care because
failure of poor prognosis
   
 an abrupt change in
neurological status, e.g.,
  seizure, TIA, weakness, or  
sensory loss
 
 
 
 

SUMMARY OF MEDICAL DECISION MAKING

 
 
 MEDICAL      
STRAIGHT- 
 DECISION LOW  MODERATE  HIGH 
FORWARD
 MAKING

 Dx/Mgmt  0-1 elements  2 elements  3 elements  >3 elements

 Data  0-1 elements  2 elements  3 elements  >3 elements

 Risk  Minimal  Low  Moderate  High

Medical Decision Making

(requires 2/3 elements to be met or exceeded)**
   1995 Requirements*
   1997 Requirements

 Number of Diagnoses/Management Options :  Number of Diagnoses/Management Options

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 Evaluation and Management (E/M) Services 21

Minimal: self-limited or minor problem or stable, Minimal: self-limited or minor problem or stable,
improving established problem improving established problem
Limited: Worsening established problem Limited: Worsening established problem
Multiple: New problem with no additional work Multiple: New problem with no additional work up
up required required
Extensive: New problem with additional work up Extensive: New problem with additional work up
planned,  Number of Diagnoses/Management planned, Number of Diagnoses/Management
Options Options
 Amount of Data Reviewed  Amount of Data Reviewed

Six elements of consideration: Six elements of consideration:

(1) ordering of diagnostic service, (1) ordering of diagnostic service,
(2) review of test results, (2) review of test results,
(3) decision to obtain old records/additional history (3) decision to obtain old records/additional history
information from family or other source, information from family or other source,
(4) documentation of relevant elements (4) documentation of relevant elements
from review of old records/other source, from review of old records/other source,
(5) discussion with physician performing diagnostic (5) discussion with physician performing diagnostic
tests or tests or
(6) direct visualization / independent interpretation (6) direct visualization / independent interpretation
of test results. of test results.

Minimal or None: only one element Minimal or None: only one element
Limited: 2 elements Limited: 2 elements
Moderate: 3 elements Moderate: 3 elements
Extensive: 4 or more elements Extensive: 4 or more elements
Risk of Complication/Comorbity  Risk of Complication/Comorbity

Patient's risk of significant complications, morbidity Patient's risk of significant complications,

or mortality using Table of Risk as a guide. This morbidity or mortality using Table of Risk as a
table delineates presenting problem(s), diagnostic guide. This table delineates presenting problem(s),
procedure(s)  ordered and management options diagnostic procedure(s) ordered and management
selected as: options selected as:
minimal, low, moderate or high. minimal, low, moderate or high.

The highest level of risk in any one category in the The highest level of risk in any one category in the
Table of Risk determines the overall risk. Table of Risk determines the overall risk.

** There is no difference in the medical decision making component between 1995 and 1997 criteria.

 B. Time and Counseling and/or Coordination of Care

In the case where counseling and/or coordination of care dominates (more than 50%) of the
physician/patient and/or family encounter (face-to-face in the office or other outpatient setting or
floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to
qualify for a particular level of E/M services. This includes time spent with parties who have assumed

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Evaluation and Management (E/M) Services 22

responsibility for the care or decision making of the patient, whether or not they are family members (e.g.
foster parents, legal guardians, locum parentis).

 If the physician elects to report the level of service based on counseling and/or coordination of
care, the total length of time of the encounter (face-to-face or floor/unit time, as appropriate)
should be documented and the record should describe the counseling and/or activities performed
to coordinate care.

Counseling is defined as one or more of the following areas:  

 Diagnostic results, impressions, and/or recommended diagnostic studies;

 Prognosis;
 Risks and benefits of management (treatment) options;
 Instructions for management (treatment) and/or follow-up;
 Importance of compliance with chosen management (treatment) options;
 Risk factor reduction; and
 Patient and family education.

Time is the explicit factor in selecting the following level of E/M service codes: hospital discharge day
management, critical care services, prolonged physician services, physician standby service, care plan
oversight services, and preventive medicine counseling.

The inclusion of time in certain E/M service codes (e.g., new and established patient, office or other
outpatient services) are averages, and therefore represent a range of times which may be higher or lower
depending on actual clinical circumstances.

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